Provider Demographics
NPI:1083011233
Name:PELTON GLOVER DENTAL PC
Entity Type:Organization
Organization Name:PELTON GLOVER DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PELTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-731-3131
Mailing Address - Street 1:13610 24 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-2400
Mailing Address - Country:US
Mailing Address - Phone:586-731-3131
Mailing Address - Fax:
Practice Address - Street 1:13610 24 MILE RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-2400
Practice Address - Country:US
Practice Address - Phone:586-731-3131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI136261223G0001X
MI141921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty